Increasing Acceptance, Comfort and Use of Placing Mother and Neonate Skin to SkinImmediately After Birth

What did you set out to improve?Immediate skin to skin contact between mother and newborn is supported in the literature (Moore 2007, Winberg 2005, Mercer 2007) with evidence that it promotes neonatal thermoregulation, breastfeeding and bonding. Although there is no policy in our institution preventing skin to skin practice, it was routine for a newborn to be placed on warmer after birth for assessment and other tasks related to infant care. Neonatal staff is called to the room when risk factors are present such as meconium stained fluid or recent maternal medication. Most of these neonates are vigorous at birth but were still whisked to the warmer for assessment. Our initiative to promote skin to skin sought to identify and breakdown barriers, educate nursing and medical staff about the supporting evidence, and provide talking points for patient education. The goal was to change the culture and make placing mother and newborn skin to skin immediately after birth standard practice.

How did you change it?We developed a step wise process to facilitate changes related to a return to normalcy (see attached) We first gathered the evidence which supported the practice of skin to skin care and identified patient health benefits. We met with neonatal nurse practitioners, L&D RNs, and nurse midwives both informally and during staff meetings to identify barriers and brainstorm ways to overcome barriers. At the same time we shared the supporting literature and discussed benefits. A promotional poster was developed which simply stated benefits and how to implement practice. This was posted in each birth room as a reminder of benefits and to educate mothers of benefits prior to delivery. At change of shift huddles or team meetings over a period of weeks, a 2 minute sound bite was given highlighting the evidence behind the practice, benefits and how to implement. Additionally a handout was developed (see attached) that was given out prenatally to women to highlight advantages.

Who was involved in making the change and what was each person’s role?The Skin-2-Skin Initiative included three point people: a nurse-midwife, a neonatal nurse-practitioner and a L&D RN. Each person was responsible for discussing benefits and identifying barriers within their collegial group. We encouraged staff members to directly contact any point person if they had questions or concerns about expectations. Since this was primarily a nurse-midwife initiative, the nurse-midwife developed the poster. The nurse-midwives were expected to model and promote the practice for nurses during midwife deliveries and for resident physicians when staffing their deliveries.

How did you determine if the change worked?Gradually midwives began seeing nurses educating patients about the benefits of skin to skin contact after birth to prepare them for the practice. Both the RNs and the neonatal nurse practitioners were also accepting of the practice with increased willingness to assess baby on mother’s chest and delay some tasks related to newborn care. We set a goal of 30 minutes of skin to skin contact in the first hour of life but any skin to skin contact is considered success

What was the biggest barrier to making the change?Surprisingly the biggest barrier was and is our patients. Many patients rejected the idea of having the baby placed on their chest without being cleaned up. Two years after the skin to skin initiative, an informal poll of RNs found that many new staff members are not sure how to discuss this practice with patients. Staff continues to verbally support the practice but feel that patient resistance is a barrier.

How did you overcome that barrier?Overcoming the barrier of patient resistance starts with education prenatally as well as in labor and delivery. Prenatally we use a birth plan to facilitate a discussion with women about the benefits of skin-to-skin at the time of delivery. When the women is admitted in labor the RNs have a positive script to discuss the practice. We have a poster in every room (see attached) briefly describing the benefits and practical application. Rather than bluntly asking if patients want baby put skin to skin, it is suggested that the practice be addressed as a standard of care which helps their new baby transition. For example: “ When the baby is born, we find putting baby directly on your chest, skin to skin, helps the baby stay warm and breathe easier. It can also help with easier breastfeeding. We will place a warm blanket over you and the baby to keep your comfortable.” Telling mothers that we know that babies who go skin to skin will regulate their temperature better and may breastfeeding easier provides a reasonable rationale. Addressing the practice as a standard of care which helps a new baby transition will provide new mothers with motivation for acceptance of the practice. Those mothers who feel more comfortable keeping their bras on can be assisted near delivery or shortly after in adjusting their undergarments to facilitate skin to skin contact. Asking patients if they have any questions or concerns regarding the practice or how it is implemented opens the door to discussion including alternative or modified ways to provide maternal (or paternal) skin to skin contact. Patients who still object after understanding the rationale for the practice will have their decision respected. Delivery providers can set the expectation that patients will be educated and prepared for skin to skin. This also sends the message as to the importance of this practice.

If you have data or other evidence that your change was successful, provide dataWe consider this initiative successful because the practice is now considered standard of care and has acceptance which has extended to physician practice. We have not collected any formal data and continue to work on this initiative.

If you had one piece of advice for someone who wanted to make a similar change in their setting, what would it be?Researching the evidence to support the practice and involving staff in implementation is crucial. Having good evidence of the benefits of skin to skin made this practice practically self-sell. Simply making staff aware of benefits went a long way to motivate staff to implement. Involving staff in brain storming what barriers exist and how to overcome them also created an ownership of the practice and its success. Change agents need to be aware that over time, motivation may wane. Renewing awareness of the benefits of the practice and addressing effective communication strategies with new staff needs to be ongoing.